Guide Lines for Guide Lines for Management of Management of

Genitourinary Malignancy.Genitourinary Malignancy.2. Prostate Cancer.2. Prostate Cancer.

Mohamed S. ZaghloulMohamed S. Zaghloul Hussein KhaledHussein Khaled Moneir Aboul EllaMoneir Aboul Ella

DiagnosisDiagnosis

Prostatic symptoms + transrectal Prostatic symptoms + transrectal ultrasound (TRUS) and biopsies from ultrasound (TRUS) and biopsies from all lobes of the prostate. all lobes of the prostate.

Pathologic exam should include.Pathologic exam should include. - Tumor grade (WHO). - Tumor grade (WHO). - Gleason's score 1-5 + 1-5- Gleason's score 1-5 + 1-5

Work upWork up LaboratoryLaboratory

CBCCBC S. Creatinine S. Creatinine PSA (total &free)PSA (total &free) LFTSLFTS

ImagingImaging Chest x-rayChest x-ray CT abdomen and pelvisCT abdomen and pelvis Bone scan (if PSA is more than 10,high S. Bone scan (if PSA is more than 10,high S.

alkaline phosphatase , tender or painful bony alkaline phosphatase , tender or painful bony symptoms )symptoms )

MRI pelvis (optionalMRI pelvis (optional).).

Staging:Staging: according toTNM classification system according toTNM classification system

TreatmentTreatment Stage I&II : with intact prostatic Stage I&II : with intact prostatic

capsule: capsule: EitherEither nerve sparing radical prostatectomy nerve sparing radical prostatectomy oror radical radiotherapy with, at least, radical radiotherapy with, at least,

conformal radiotherapy (70-80 Gy).conformal radiotherapy (70-80 Gy).

PORTPORTIndications of PORT after radical Indications of PORT after radical

prostatectomy:prostatectomy:

i. Capsular infiltration.i. Capsular infiltration. ii. Seminal vesicle ii. Seminal vesicle

infiltration.infiltration. iii. Positive safety margin.iii. Positive safety margin.

TreatmentTreatment Stage III: Stage III: Neoadjuvant hormonal manipulation by Neoadjuvant hormonal manipulation by

LHRH agonist (with antiandrogen for the LHRH agonist (with antiandrogen for the first 2 weeks)(Goserelin “Zoladex” or first 2 weeks)(Goserelin “Zoladex” or Leuproline “Leuporon” , for 2 months Leuproline “Leuporon” , for 2 months before and 2 months during before and 2 months during radiotherapy) 70 Gy radical radiotherapy radiotherapy) 70 Gy radical radiotherapy whole pelvis for 50 Gy and 20 Gy boost whole pelvis for 50 Gy and 20 Gy boost to the prostate. to the prostate.

Maintenance LHRH agonist for 6-24Maintenance LHRH agonist for 6-24 months (for high risk patients). months (for high risk patients).

TreatmentTreatment Stage IV (metastatic): Stage IV (metastatic): Bilateral subcapsular orchiectomy ± flutamide Bilateral subcapsular orchiectomy ± flutamide

daily orally or androcure 250 mg/day.daily orally or androcure 250 mg/day. Second line hormonal therapy:Second line hormonal therapy: Bicalutamide (Casodex) 50-100 mg daily orallyBicalutamide (Casodex) 50-100 mg daily orally Palliative radiotherapy to bone metastasisPalliative radiotherapy to bone metastasis Hormone refractory or resistant patientsHormone refractory or resistant patients - Mitoxantrone (Novantron) 12 mg/m2 every 3 - Mitoxantrone (Novantron) 12 mg/m2 every 3

wks + prednisone 10 mg daily.wks + prednisone 10 mg daily. - 2nd line: Docetaxil (Taxotere) 75 mg/m2 every- 2nd line: Docetaxil (Taxotere) 75 mg/m2 every 3 weeks.3 weeks.

TreatmentTreatment Management of biochemical failure Management of biochemical failure

after radical treatment:after radical treatment: (Biochemical failure is defined as (Biochemical failure is defined as

serum prostate specific antigen levels serum prostate specific antigen levels of 0.4 ng/ml following surgery, 0.5 of 0.4 ng/ml following surgery, 0.5 ng/ml following radiotherapy and/or 2 ng/ml following radiotherapy and/or 2 consecutive rising prostate specific consecutive rising prostate specific antigen values 3 months apart). antigen values 3 months apart).

Patients with biochemical failure need Patients with biochemical failure need to be investigated for local or to be investigated for local or systemic recurrences. systemic recurrences.

Follow-upFollow-up

every 3 months for the first 3 every 3 months for the first 3 years, every 6 months years, every 6 months thereafter.thereafter.

3.3.Renal Carcinoma & Renal Carcinoma & Renal pelvis carcinomaRenal pelvis carcinoma

Mohamed S. ZaghloulMohamed S. Zaghloul Hussein KhaledHussein Khaled Moneir Aboul EllaMoneir Aboul Ella

Work upWork up * * LaboratoryLaboratory

CBCCBC S. Creatinine S. Creatinine LFTSLFTS

* * RadiologicRadiologic Chest x-rayChest x-ray CT abdomen and pelvis (or IVU + CT abdomen and pelvis (or IVU + abdominopelvic US)abdominopelvic US)

Bone scan (optional)Bone scan (optional)

TreatmentTreatment 1.1.Renal cell Ca.Renal cell Ca. Resectable cases:Resectable cases:

Radical nephrectomy: Radical nephrectomy: complete complete removal of Gerota’s fascia and removal of Gerota’s fascia and its content including the adrenal its content including the adrenal gland, kidney and perinephric gland, kidney and perinephric fat. It may include resection of fat. It may include resection of hilar LN or even regional LN.hilar LN or even regional LN.

Post operative radiotherapyPost operative radiotherapy may be added in the following :may be added in the following :

1. Invasion of the 1. Invasion of the capsulecapsule

2. Positive LN.2. Positive LN. 3. Positive safety 3. Positive safety

margin ormargin or residual tumors.residual tumors.

Metastatic Renal Cell CaMetastatic Renal Cell Ca i. Metastatectomy in pulmonary or brain i. Metastatectomy in pulmonary or brain

metastases (maximum 3 separate metastases (maximum 3 separate metastases).metastases).

ii.Palliative nephrectomy and/or removal of ii.Palliative nephrectomy and/or removal of metastatic focimetastatic foci

in the following conditions.in the following conditions. No central nervous system, bone or liver No central nervous system, bone or liver

metastases.metastases. Adequate pulmonary and cardiac functions.Adequate pulmonary and cardiac functions. Good performance status.Good performance status. Predominantoly clear cell histology.Predominantoly clear cell histology. Severe renal symptoms eg repeated Severe renal symptoms eg repeated

hemorrhages, tumor pain or significant hemorrhages, tumor pain or significant paraneoplastic syndrome.paraneoplastic syndrome.

Metastatic Renal Cell CaMetastatic Renal Cell Ca

iii. Cytoreductive maneuvers : embolization , iii. Cytoreductive maneuvers : embolization , chemoembolization, ….chemoembolization, ….

iv. Palliative radiotherapy or chemotherapyiv. Palliative radiotherapy or chemotherapy and biologic therapy and biologic therapy - (Interferon 3 million units every other day- (Interferon 3 million units every other day and Vinblatine 0.1 mg/kg body weightand Vinblatine 0.1 mg/kg body weight every 3 weeks then reevaluation). every 3 weeks then reevaluation).

Ca. of Renal pelvisCa. of Renal pelvis a.a. Resectable cases Resectable cases Radical nephrouretrectomy with Radical nephrouretrectomy with

removal of a bladder cuff.removal of a bladder cuff.

Adjuvant PORT is added in:Adjuvant PORT is added in: 1. Large tumors invading the renal1. Large tumors invading the renal capsule or Gerota's fascia.capsule or Gerota's fascia. 2. high grades.2. high grades.

b. Inoperable casesb. Inoperable cases : are palliated by : are palliated by palliative radiotherapy or as metastatic palliative radiotherapy or as metastatic

cases cases c. c. Metastatic renal pelvis Ca. Metastatic renal pelvis Ca. Palliative radiotherapy or chemotherapy usingPalliative radiotherapy or chemotherapy using Gemcitabine Gemcitabine 1000 mg/m2 1000 mg/m2 D1 & D8D1 & D8 Cisplatin Cisplatin 70 mg/m2 70 mg/m2 D2D2 Every 3 weeks.Every 3 weeks.

Testicular cancerTesticular cancer

Mohamed S. ZaghloulMohamed S. Zaghloul Hussein KhaledHussein Khaled Moneir Aboul EllaMoneir Aboul Ella

DiagnosisDiagnosis

Any solid testicular mass should Any solid testicular mass should be diagnosed by scrotal US be diagnosed by scrotal US followed by inguinal high followed by inguinal high orchiectomy (no direct testicular orchiectomy (no direct testicular or fine needle aspiration biopsy).or fine needle aspiration biopsy).

CT-guided biopsy is recommended CT-guided biopsy is recommended for diagnosis of tumour on top of for diagnosis of tumour on top of abdominal undescended testis.abdominal undescended testis.

Work upWork up LaboratoryLaboratory

CBCCBC LFTS, S. Creatinine LFTS, S. Creatinine AFP, βHCG, LDHAFP, βHCG, LDH

RadiologicRadiologic Chest x-ray (CT in retroperitoneal Chest x-ray (CT in retroperitoneal positive lymphadenopathy).positive lymphadenopathy).

Abdominopelvic CT (or IVU & Abdominopelvic CT (or IVU & bipedal lymphangiography).bipedal lymphangiography).

TreatmentTreatment Inguinal high orchiectomy Inguinal high orchiectomy

and biopsy of the other and biopsy of the other testis.testis.

Active treatment according Active treatment according to the stage.to the stage.

ObservationObservation

is recommended only for is recommended only for stage IA compliant patients.stage IA compliant patients.

Pelviabdominal CT every 2 months Pelviabdominal CT every 2 months during the first year & every 4 monthsduring the first year & every 4 months

thereafter.thereafter.

Treatment of relapsed cases Treatment of relapsed cases a. relapsed stage I cases who did not a. relapsed stage I cases who did not

receive radiotherapy :receive radiotherapy : i) Non bulky (< 5 cm) are treated with i) Non bulky (< 5 cm) are treated with

radiotherapy 35- 40 Gy.radiotherapy 35- 40 Gy. ii) Bulky (≥ 5 cm) ,received radiotherapy ii) Bulky (≥ 5 cm) ,received radiotherapy

or having visceral oror having visceral or pulmonary disease are treated withpulmonary disease are treated with chemotherapy as mentionedchemotherapy as mentioned above (as stages IIc and III).above (as stages IIc and III). b. relapsed stage II & III are treated withb. relapsed stage II & III are treated with second line chemotherapy.second line chemotherapy.

Response Evaluation, further Response Evaluation, further management & follow up:management & follow up:

CT scan has to be done 1-2 months post CT scan has to be done 1-2 months post treatment. If normal follow up to be treatment. If normal follow up to be performed every 2 months during the first performed every 2 months during the first year and every 4 months thereafter. If year and every 4 months thereafter. If abnormal and the mass is ≥ 3 cm either abnormal and the mass is ≥ 3 cm either resect the mass or radiotherapy (if no resect the mass or radiotherapy (if no previous radiotherapy given). If the mass is < previous radiotherapy given). If the mass is < 3 cm observe till the mass progress treat as 3 cm observe till the mass progress treat as above. above.

NB: If PET scan is available it will be of great NB: If PET scan is available it will be of great help in detecting residual disease.help in detecting residual disease.

Non- Seminoma Non- Seminoma Nerve- sparing retroperitoneal lymph Nerve- sparing retroperitoneal lymph

node dissection (RPLND) :node dissection (RPLND) : 1. If LN are negative : Observation.1. If LN are negative : Observation. 2. If LN are positive either observe 2. If LN are positive either observe

oror give chemotherapy in non-give chemotherapy in non-

compliantcompliant patients or if there are extensivepatients or if there are extensive nodal involvement.nodal involvement.

Stage IBStage IB there are 2 options:there are 2 options: i. RPLND.i. RPLND. ii. Chemotherapy 2 courses of BEP.ii. Chemotherapy 2 courses of BEP. Stage ISStage IS : : Chemotherapy in the form of 4 cycles of EP or 3Chemotherapy in the form of 4 cycles of EP or 3 cycles of BEP.cycles of BEP. Stage II (A or B):Stage II (A or B): i) If Tumor markers are not elevated patients are i) If Tumor markers are not elevated patients are

treated by either RPLND + adjuvant 2 courses of treated by either RPLND + adjuvant 2 courses of chemotherapy chemotherapy OROR 4 courses of EP or 3 courses of 4 courses of EP or 3 courses of BEP.BEP.

ii) If markers are elevated give chemotherapy.ii) If markers are elevated give chemotherapy.

Stage IIC & III and Stage IIC & III and extragonadal primary sites extragonadal primary sites

(Mediastinum or (Mediastinum or retroperitoneimretroperitoneim

Primary Chemotherapy according to Primary Chemotherapy according to riskrisk

status.status. i) Good risk : either 4 cycles of EP or i) Good risk : either 4 cycles of EP or

3 cycles of PEB.3 cycles of PEB. ii) Intermediate or poor risk : 4 cycles ii) Intermediate or poor risk : 4 cycles

of PEB.of PEB.

Incompletely responded or Incompletely responded or relapsed patientsrelapsed patients

treated with surgical salvage if treated with surgical salvage if presentedpresented

in a single site.in a single site. Resistant cases are treated with Resistant cases are treated with

third line (high-dose) chemotherapy.third line (high-dose) chemotherapy. Third line chemotherapy consisted of Third line chemotherapy consisted of

2 cycles of high dose carboplatin and 2 cycles of high dose carboplatin and etoposide ± cyclophosphamide (or etoposide ± cyclophosphamide (or ifosphamide).ifosphamide).

Follow-upFollow-up Every 3 months in the first Every 3 months in the first

years & every 6 months years & every 6 months thereafter. thereafter.

CXR and CT abdomen to CXR and CT abdomen to be performed every year be performed every year